In the healthcare field, a good faith estimate (GFE) helps to reduce the confusion that patients experience when they are billed for services. Healthcare pricing is a tedious and mysterious subject for most patients. The No Surprises Act requires you to provide GFEs for most patients and scenarios, making it essential for compliance and for building trust with your population.
If you’re searching, “What is good faith estimate in healthcare?” understanding how it impacts your services is key. Mastering the good faith estimate will promote compliance with federal laws like the No Surprises Act and build confidence among your patient population. Here’s what you need to know.
To understand the Good Faith Estimate (GFE), let’s first dive into the No Surprises Act;
The legislation in which the GFE is found. Effective January 1, 2022, the No Surprises Act (NSA) is a collection of federal rules designed by the Department of Health and Human Services (HHS) with other federal departments to protect medical patients from surprise billing.
Specifically, the No Surprises Act protects self-pay and uninsured patients (we'll say self-pay here to refer to both) from receiving bills that are substantially more than expected. It also protects patients with insurance coverage from receiving unexpected medical bills from out-of-network (OON) facilities or providers for certain emergency or non-emergency services.
To protect self-pay patients from receiving bills for substantially more than expected, the No Surprises Act requires virtually all healthcare facilities and providers to:
Answering the question, “What is good faith estimate?” is only the beginning, though. Learning how to complete a good faith estimate can be difficult, as you’ll need to take a different approach for insured patients and self-pay clients.
When serving uninsured or self-pay patients, you are legally required to provide a good faith estimate for scheduled services or upon request. These estimates must include an itemized breakdown of services, a list of providers involved, and the patient’s basic identifying information.
Insured patients are also entitled to a GFE, provided that they obtained their coverage privately or via an employer. Medicaid and Medicare patients are often exempt from good faith estimate requirements. However, there can be some gray areas, so it’s important to consult with your compliance and legal teams.
Something to keep in mind: If the actual charges billed are $400 or more than the GFE, the self-pay patient may initiate what’s called the selected dispute resolution process (SDR) to determine what the patient must pay. For GFEs, the SDR process is also known as the patient-provider dispute resolution (PPDR) process.
Healthcare providers and facilities are currently only federally required to offer GFEs to self-pay patients in 2022; however, some states may require GFEs for insured patients (e.g., Indiana and Ohio). Check your local laws to be sure you are providing estimates compliant with your state legislation.
Where to post: On the provider’s or facility’s website, in the office, and wherever scheduling or questions about healthcare costs occur.
The patient may be eligible to initiate the SDR process for incomplete or inaccurate GFEs, so it is imperative to provide new, more accurate GFEs if changes are made to planned care before services are rendered.
Every GFE needs to have the patient’s name and date of birth, the office or facility location(s), service codes, diagnosis codes, expected charges, names of providers and facilities, national provider identifier (NPI), date(s) of service(s), tax ID number, disclaimers, description of primary item or service; and an itemized list of items and services, grouped by each provider or facility.
CMS has a free downloadable template that can be utilized to stay compliant; however, Rivet’s software not only allows providers to offer clean good faith estimates for insured and self-pay patients, but also allows providers to check eligibility, manage their payer-provider contracts, and collect up-front payment from patients.
Below are descriptions of each data element needed and how Rivet’s software is compliant with these requirements. Click the picture for more details.
The NSA requires national drug codes (NDCs), and Rivet is currently making updates to accommodate this requirement. Currently, Rivet’s notes section can be utilized to put in NDCs.
Additionally, you are required to post notices that communicate patients’ rights. The notice must inform uninsured and self-pay patients of their right to receive a good faith estimate before services are delivered.
Make sure that the notices are accessible on your website and displayed prominently in all of your office locations. The notices should be available in multiple languages, too.
Properly issuing a good faith estimate in healthcare is only part of the compliance challenge. You must also implement workflows to address the PPDR process.
The patient-provider dispute resolution process creates a formal option for uninsured or self-pay patients to challenge medical bills. To be eligible for the PPDR process, a bill must be at least $400 higher than the estimate that you provided to the patient.
Patients have 120 calendar days to initiate a dispute. The clock starts ticking the day they receive the final bill. Patients must initiate the dispute process themselves, and they are required to provide the final bill and the good faith estimate.
The reviewer will determine whether the additional charges are justified based on the scope of care that the patient received. If the reviewer rules in favor of the patient, you may have to reduce your charges accordingly.
Situation
Provide the GFE:
An item or service is scheduled 3–9 business days before the date of the item or service is rendered.
No later than 1 business day after the date of scheduling.
An item or service is scheduled at least 10 business days before the date of the item or service is rendered.
No later than 3 business days after the date of scheduling.
A self-pay patient requests a GFE.
No later than 3 business days after the date of the request.
Changes to the original GFE are anticipated (e.g., changes to the charges, items, services, providers, or facilities, etc.).
No later than 1 business day before the items or services are scheduled to be rendered.
Note: If changes to providers or facilities are made less than 1 business day before the scheduled item or service, the replacement provider or facility must accept the previous GFE as their GFE. Always be sure to check for any prior GFE before assuming care less than 1 business day before the scheduled item or service.
This is not a comprehensive look at all the nuances of the No Surprises Act or the good faith estimate. For more information, see CMS.go.
Rivet’s Estimates software offers accurate, good faith estimates that you can send to patients via HIPAA-compliant text and/or email, or print out the estimate right in your office. Patients will see their deductible/out-of-pocket maximum met, diagnostic codes, their financial responsibility, and their plan’s financial responsibility, prior authorization flags, customized disclaimers,s and more.
To see Rivet's Estimates and discuss billing pain points, request a demo now.
The No Surprises Act establishes clear rules for issuing a good faith estimate in healthcare. These rules apply to individuals who have purchased healthcare plans through their employers or independently.
Providers are required to issue patients a good faith estimate for scheduled services or upon request. The breakdown must include a clear, itemized list of expected charges.
Providers are also required to include identifying information for patients and the providers involved, along with applicable diagnosis and service codes when available. The issuer must include a disclaimer as well.
Additionally, providers need to post a notice informing patients of their right to receive a good faith estimate. Generally, GFE rules do not apply to a Medicare or Medicaid health plan.
The timeframe for providing a good faith estimate depends on when the service is scheduled or when the patient requests the estimate. Typically, providers must issue a GFE within three business days of the scheduled date of service, provided that it is booked at least 10 business days in advance.
If a patient requests a good faith estimate without scheduling service, the provider must still respond within 3 business days. These timelines are strict and tied directly to compliance requirements. Your organization could face fines or other penalties for failing to adhere to good faith estimate requirements.
A good faith estimate gives patients a clear understanding of their expected healthcare costs before receiving services. Patients can use this information to make informed decisions about whether to proceed with care, compare options, or plan financially for upcoming expenses. Uninsured or self-pay patients also have access to new dispute resolution options when they incur surprise hospital fees.
The GFE process applies to in-person visits, including emergency room visits and standard service appointments. The goal of the process is to give patients more control over their decision-making process.
Additionally, if the final bill exceeds the estimate by $400 or more, patients can initiate a formal dispute process. The No Surprises Act creates accountability for providers to generate accurate estimates.
A good faith estimate must include a comprehensive and itemized breakdown of all expected charges related to a patient’s care. The document should also include basic patient information used for medical records.
GFEs need to list the scheduled services and provide a cost estimate. It’s important to include all reasonably expected items, such as facility charges, lab work, and imaging.
Finally, your good faith estimates should include the names of providers and facilities involved. If available, add service and diagnosis codes for more effective billing.
The 72-hour rule, or three-day payment window, applies to how hospitals bundle certain outpatient services with inpatient admissions for billing purposes. If a patient receives outpatient services at a hospital within 72 hours before being admitted, those services are typically combined into the inpatient claim.
The 72-hour rule is not part of the good faith estimate requirements. It can affect how providers calculate expected costs. If there is a possibility that outpatient services could lead to an inpatient admission, estimates should account for how those services may ultimately be billed.
